Maternal-Fetal Medicine Practice Questions

Q: A non-stress test (NST) of a multigravida who is diabetic shows late decelerations. Which of the following is NOT true about late decelerations?

Caused by head compression. **Explanation:** The correct answer is **A (Caused by head compression)** because head compression is the physiological cause of **Early Decelerations**, not late decelerations. Early decelerations are mediated by a vagal response and are considered benign. **Understanding Late Decelerations:** Late decelerations are a sign of **uteroplacental insufficiency**. They occur when the oxygen reserve in the intervillous space is so low that the transient decrease in blood flow during a contraction leads to fetal hypoxemia and myocardial depression. * **Option B & D (Incorrect):** These describe the classic morphology of a late deceleration. The nadir (lowest point) of the fetal heart rate occurs **after the apex** (peak) of the uterine contraction. The deceleration is "late" because it lags behind the contraction. * **Option C (Incorrect):** This is the primary underlying etiology. Conditions like maternal diabetes, hypertension, or post-term pregnancy can lead to placental insufficiency, manifesting as late decelerations on a Non-Stress Test (NST). **High-Yield Clinical Pearls for NEET-PG:** * **Early Decelerations:** "Mirror image" of the contraction; caused by **Head Compression** (Benign). * **Variable Decelerations:** Abrupt onset; vary in timing; caused by **Umbilical Cord Compression** (Most common type). * **Late Decelerations:** Gradual onset; nadir after the peak of contraction; caused by **Uteroplacental Insufficiency** (Ominous/Non-reassuring). * **Management:** For persistent late decelerations, the immediate steps include lateral decubitus positioning, oxygen supplementation, IV fluids, and potentially urgent delivery if the pattern persists.

Q: What is the normal range of Amniotic Fluid Index (AFI)?

5 to 24 cm. The **Amniotic Fluid Index (AFI)** is a semi-quantitative assessment used to monitor fetal well-being. It is calculated by dividing the uterus into four quadrants using the umbilicus and the linea nigra as landmarks, then summing the vertical depth (in cm) of the largest pocket of fluid in each quadrant. ### **Explanation of Options** * **Correct Answer (D) 5 to 24 cm:** In clinical practice, an AFI between **5 cm and 24 cm** is considered the normal physiological range. * **AFI 24 cm** (or 25 cm in some texts) is the threshold for **Polyhydramnios**. * **Option A & C (2 cm):** The value "2 cm" refers to the **Single Deepest Pocket (SDP)** or Maximum Vertical Pocket (MVP) method. An SDP 8 cm indicates polyhydramnios. * **Option B (5 to 8 cm):** This range is too narrow. While an AFI of 5–8 cm is sometimes termed "borderline" or "low-normal," it is not the standard definition of the entire normal range. ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard:** While AFI is commonly used, the **Single Deepest Pocket (SDP)** is often considered superior in twin pregnancies and for reducing unnecessary interventions in post-term pregnancies. * **Peak Volume:** Amniotic fluid volume peaks at approximately **34–36 weeks** (roughly 800–1000 mL) and gradually declines thereafter. * **Common Associations:** * **Oligohydramnios:** Renal agenesis (Potter sequence), PROM, and Placental insufficiency. * **Polyhydramnios:** Gestational diabetes, Tracheoesophageal fistula, and Anencephaly.

Q: A 31-year-old woman presents with abdominal pain and vaginal spotting, which began 2 days ago and has been worsening. The spotting started this morning. Her last menstrual period was 6 weeks ago. She has no medical problems, takes no medications, and has no known drug allergies. Her vital signs are: temperature 37°C (98.6°F), blood pressure 90/50 mm Hg, pulse 110/min, and respirations 14/min. Abdominal examination reveals significant lower abdominal tenderness. Speculum examination shows scant blood in the vagina with a closed cervical os. Bimanual examination demonstrates significant left adnexal tenderness. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. In MOST cases, the disease process of this patient affects which of the following anatomic structures?

Fallopian tube. **Explanation:** The patient presents with the classic triad of **ectopic pregnancy**: amenorrhea (LMP 6 weeks ago), abdominal pain, and vaginal bleeding. Her clinical presentation—hypotension (90/50 mmHg), tachycardia (110/min), and free fluid on ultrasound—strongly suggests a **ruptured ectopic pregnancy**, a surgical emergency. **Why the Fallopian Tube is Correct:** In approximately **95–98%** of ectopic pregnancies, the blastocyst implants within the **fallopian tube**. Within the tube, the **ampulla** is the most common site (70%), followed by the isthmus (12%), fimbriae (11%), and interstitium (2%). The lack of a gestational sac in the uterus despite a serum hCG above the discriminatory zone (>2,000–3,500 mIU/mL) and an adnexal mass confirms the diagnosis. **Why Other Options are Incorrect:** * **A. Cervix:** Cervical pregnancies are rare (<1%) and typically present with painless vaginal bleeding and a "hourglass" shaped uterus. * **C. Ovary:** Ovarian pregnancies occur in only 1–3% of cases. They are often confused with hemorrhagic corpus luteum cysts. * **D. Peritoneal cavity:** Primary abdominal pregnancy is extremely rare (approx. 1%). While the "free fluid" (hemoperitoneum) is located in the peritoneal cavity, it is a *consequence* of the tubal rupture, not the primary site of the disease process. **NEET-PG High-Yield Pearls:** * **Most common site overall:** Ampulla of the Fallopian tube. * **Most dangerous site:** Interstitial/Cornual (due to late presentation and risk of massive hemorrhage from the uterine artery). * **Risk Factors:** Previous ectopic (strongest), PID (most common), tubal surgery, and smoking. * **Management:** If hemodynamically unstable (as in this case), the treatment of choice is **emergency laparotomy/laparoscopy**. If stable and hCG <5,000, medical management with **Methotrexate** may be considered.

Q: Administration of antiretroviral therapy during the peripartum period decreases the risk of vertical transmission by what percentage?

65%. The correct answer is **65% (Option C)**. ### **Explanation** The risk of vertical transmission of HIV from an untreated mother to her child is approximately **25–30%**. The landmark **PACTG 076 trial** established that the administration of Zidovudine (AZT) during the antepartum, intrapartum, and neonatal periods reduces the risk of transmission by approximately **two-thirds (66-67%)**, bringing the transmission rate down to about 8%. In the context of standard medical examinations like NEET-PG, **65%** is the recognized value for this reduction. ### **Analysis of Options** * **Option A (30%):** This represents the baseline risk of transmission in an untreated patient (without any interventions). * **Option B (50%):** This is an underestimate. Monotherapy or short-course prophylaxis provides a more significant reduction than 50%. * **Option D (75%):** While modern Highly Active Antiretroviral Therapy (HAART) combined with a viral load 95% reduction), the specific historical benchmark for peripartum ART efficacy is 65-67%. ### **NEET-PG High-Yield Pearls** * **Most common route of transmission:** Intrapartum (during labor and delivery) is the period of highest risk. * **PPTCT Protocol (India):** All HIV-positive pregnant women should be started on **Lifelong ART** (TDF + 3TC + EFV/DTG) regardless of CD4 count or clinical stage. * **Mode of Delivery:** If the viral load is **>1000 copies/mL** at 36 weeks, a **Pre-labor Cesarean Section** is recommended to further reduce risk. * **Breastfeeding:** In India, exclusive breastfeeding for 6 months is recommended if the mother is on ART, though replacement feeding is preferred only if it is AFASS (Affordable, Feasible, Acceptable, Sustainable, and Safe).

Q: A woman delivered a child after a normal prenatal period. One hour postpartum, she experienced a stroke. What is the probable cause?

Amniotic fluid embolism. **Explanation:** The correct answer is **Amniotic Fluid Embolism (AFE)**. AFE is a rare but catastrophic obstetric emergency characterized by the entry of amniotic fluid, fetal cells, or debris into the maternal circulation. It typically occurs during labor or in the immediate postpartum period (usually within the first hour). The pathophysiology involves a systemic inflammatory response syndrome (SIRS) rather than a simple mechanical obstruction. This leads to a classic triad of **hypotension, hypoxia, and coagulopathy (DIC)**. Neurological manifestations, including seizures or **embolic stroke**, are recognized complications due to paradoxical embolism or severe cerebral hypoxia/hypoperfusion. **Why other options are incorrect:** * **APLAS (B):** While APLAS is a prothrombotic state that can cause strokes, it is a chronic condition usually associated with recurrent pregnancy loss or preeclampsia. It does not typically present as an acute, catastrophic event specifically within one hour of a normal delivery without prior history. * **Choriocarcinoma (C):** This is a gestational trophoblastic neoplasm. While it can metastasize to the brain and cause hemorrhage/stroke, it typically presents weeks to months after delivery, often with persistent vaginal bleeding and elevated β-hCG levels. * **Sheehan’s Syndrome (D):** This refers to postpartum pituitary necrosis due to severe obstetric hemorrhage. It presents with failure to lactate or amenorrhea in the weeks/months following delivery, not an acute stroke. **Clinical Pearls for NEET-PG:** * **AFE Diagnosis:** Primarily clinical; "Diagnosis of exclusion." * **Key finding on autopsy:** Squamous cells or fetal debris in the maternal pulmonary vasculature. * **Management:** Supportive (A-B-C) and aggressive management of DIC. * **Risk Factors:** Advanced maternal age, multiparity, and placental abruption.

Q: Which of the following is NOT associated with teenage pregnancy?

Post-dated pregnancy is more common. **Explanation:** Teenage pregnancy (defined as pregnancy in girls aged 10–19) is considered a high-risk condition due to both biological immaturity and socio-economic factors. **Why "Post-dated pregnancy" is the correct answer:** Teenage pregnancies are significantly more associated with **Preterm Labor** (delivery before 37 weeks) rather than post-dated pregnancy. This is attributed to factors such as an immature uterine blood supply, a developing cervix, and a higher prevalence of genitourinary infections. Therefore, post-dated pregnancy is **not** a characteristic feature of teenage gestation. **Analysis of Incorrect Options:** * **Cesarean section is more common:** While some studies show varying rates, the incidence of C-sections is generally higher in teenagers due to **Cephalopelvic Disproportion (CPD)**. This occurs because the maternal bony pelvis may not be fully developed or fused, making it too small for the fetal head. * **Eclampsia is more common:** Young age (nulliparity) is a major risk factor for Hypertensive Disorders of Pregnancy. Teenagers have a significantly higher predisposition to **Pre-eclampsia and Eclampsia** compared to women in their 20s. * **Maternal mortality rate is higher:** The MMR is elevated in this group due to the higher frequency of complications like obstructed labor (CPD), eclampsia, and unsafe abortions, combined with late booking or poor antenatal care. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Anemia (Iron deficiency). * **Fetal outcomes:** Higher risk of Low Birth Weight (LBW) and Intrauterine Growth Restriction (IUGR). * **Psychosocial:** Increased risk of postpartum depression and repeat pregnancy within two years. * **Key takeaway:** If a question asks for the "most common" obstetric complication in teens, think **Anemia** or **Pre-eclampsia**. If it asks for the "least likely" timing, think **Post-dated**.

Q: Which one of the following congenital malformations of the fetus can be diagnosed in the first trimester by ultrasound?

Anencephaly. **Explanation:** The correct answer is **Anencephaly**. **1. Why Anencephaly is the correct answer:** Anencephaly is a lethal neural tube defect characterized by the absence of the cranial vault (acrania) and cerebral hemispheres. With high-resolution transvaginal sonography (TVS), it can be reliably diagnosed in the late first trimester (11–14 weeks). The hallmark ultrasound findings are the **"Mickey Mouse sign"** (the appearance of preserved facial structures and orbits without a calvarium) and the **"Frog-eye appearance"** in the coronal plane. By 11 weeks, ossification of the skull should be complete; its absence confirms the diagnosis. **2. Why the other options are incorrect:** * **Inencephaly:** While a severe neural tube defect involving extreme retroflexion of the head, it is much rarer than anencephaly and often requires second-trimester imaging for a definitive diagnosis of the spinal involvement. * **Microcephaly:** This is a diagnosis of "growth" rather than "structure." It is typically diagnosed in the late second or third trimester because the head circumference must fall significantly below the mean (usually >3 SD) over time. * **Holoprosencephaly:** Although severe alobar forms can sometimes be suspected in the first trimester, it is traditionally a second-trimester diagnosis when the development of the midline structures (thalamus, falx cerebri) can be clearly assessed. **Clinical Pearls for NEET-PG:** * **Acrania-Anencephaly Sequence:** Acrania (absent skull with brain present) precedes anencephaly (brain degeneration due to exposure to amniotic fluid). * **Biochemical Marker:** Maternal Serum Alpha-Fetoprotein (MSAFP) is significantly **elevated** in open neural tube defects. * **Prevention:** 400 mcg of Folic acid daily (pre-conceptionally) reduces risk; 4 mg daily is required for women with a previous affected pregnancy.

Q: For fetal lung maturation, which of the following corticosteroids cannot be used?

Methylprednisolone. **Explanation:** The primary goal of administering corticosteroids in cases of anticipated preterm birth (24 to 34 weeks) is to accelerate fetal lung maturity and reduce the incidence of Respiratory Distress Syndrome (RDS), Intraventricular Hemorrhage (IVH), and Necrotizing Enterocolitis (NEC). **Why Methylprednisolone is the Correct Answer:** To be effective for fetal lung maturation, a corticosteroid must cross the placenta in its active form. **Methylprednisolone**, along with Hydrocortisone and Prednisolone, is extensively metabolized and inactivated by the placental enzyme **11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2)**. Consequently, these drugs do not reach the fetus in sufficient concentrations to induce surfactant production. **Analysis of Other Options:** * **Betamethasone (Option A) & Dexamethasone (Option B):** These are the only two recommended steroids for fetal lung maturity. They are fluorinated compounds that are poor substrates for 11β-HSD2, allowing them to cross the placenta easily and bind to fetal glucocorticoid receptors. * **Hydrocortisone (Option C):** Like Methylprednisolone, it is inactivated by the placenta and is not used for fetal lung maturation. However, in the context of this specific question format, Methylprednisolone is the classic "distractor" used in exams to differentiate between maternal and fetal indications. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Regimens:** * Betamethasone: 12 mg IM, 2 doses, 24 hours apart (Drug of choice). * Dexamethasone: 6 mg IM, 4 doses, 12 hours apart. * **Timing:** Maximum benefit is seen if delivery occurs between 24 hours and 7 days after the first dose. * **Indication:** All women at risk of preterm delivery between **24 and 34 weeks** of gestation. * **Mechanism:** Steroids increase the synthesis of **Surfactant** (specifically Dipalmitoylphosphatidylcholine) by Type II pneumocytes.

Q: What is the most important factor in the management of preeclampsia?

Severity of hypertension. **Explanation:** The management of preeclampsia is primarily dictated by the **severity of hypertension** and the **gestational age** of the fetus. The degree of blood pressure elevation is the most critical factor because it directly correlates with the risk of life-threatening maternal complications, such as cerebrovascular accidents (hemorrhagic stroke), placental abruption, and hypertensive encephalopathy. Management protocols (e.g., the decision to initiate antihypertensives like Labetalol or Hydralazine and the timing of delivery) are triggered by specific blood pressure thresholds (≥160/110 mmHg). **Analysis of Incorrect Options:** * **Proteinuria:** While essential for the classic diagnosis of preeclampsia, the *amount* of proteinuria does not correlate with clinical outcomes and is no longer used to define "severity" or guide management decisions according to ACOG and NHBPEP guidelines. * **Convulsions:** This defines **Eclampsia**. While critical, management aims to prevent this stage. Once convulsions occur, the diagnosis changes, and the management shifts to emergency seizure control (Magnesium Sulfate). * **Pedal Edema:** This is common in normal pregnancies and is no longer included in the diagnostic criteria for preeclampsia due to its lack of specificity. **Clinical Pearls for NEET-PG:** * **Target BP:** In severe preeclampsia, the goal is to maintain systolic BP between 140–150 mmHg and diastolic BP between 90–100 mmHg. * **Drug of Choice (DOC):** For seizure prophylaxis in preeclampsia with severe features is **Magnesium Sulfate** (Pritchard Regimen). * **Definitive Treatment:** Delivery of the fetus and placenta remains the only cure for preeclampsia. * **New Criteria:** Preeclampsia can now be diagnosed *without* proteinuria if other "severe features" (thrombocytopenia, renal insufficiency, liver dysfunction, or visual symptoms) are present.

Question 1

A non-stress test (NST) of a multigravida who is diabetic shows late decelerations. Which of the following is NOT true about late decelerations?

Accepted Answer

Caused by head compression

Answer

Fetal heart rate begins to slow down after the contraction's apex

Answer

Suggestive of placental insufficiency

Answer

Occurs after the apex of the contraction

Question 2

What is the normal range of Amniotic Fluid Index (AFI)?

Accepted Answer

5 to 24 cm

Answer

2 to 8 cm

Answer

5 to 8 cm

Answer

2 to 24 cm

Question 3

A 31-year-old woman presents with abdominal pain and vaginal spotting, which began 2 days ago and has been worsening. The spotting started this morning. Her last menstrual period was 6 weeks ago. She has no medical problems, takes no medications, and has no known drug allergies. Her vital signs are: temperature 37°C (98.6°F), blood pressure 90/50 mm Hg, pulse 110/min, and respirations 14/min. Abdominal examination reveals significant lower abdominal tenderness. Speculum examination shows scant blood in the vagina with a closed cervical os. Bimanual examination demonstrates significant left adnexal tenderness. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. In MOST cases, the disease process of this patient affects which of the following anatomic structures?

Accepted Answer

Fallopian tube

Answer

Cervix

Answer

Ovary

Answer

Peritoneal cavity

Question 4

Administration of antiretroviral therapy during the peripartum period decreases the risk of vertical transmission by what percentage?

Accepted Answer

65%

Answer

30%

Answer

50%

Answer

75%

Question 5

A woman delivered a child after a normal prenatal period. One hour postpartum, she experienced a stroke. What is the probable cause?

Accepted Answer

Amniotic fluid embolism

Answer

Antiphospholipid antibody syndrome (APLAS)

Answer

Choriocarcinoma

Answer

Sheehan's syndrome

Question 6

Which of the following is NOT associated with teenage pregnancy?

Accepted Answer

Post-dated pregnancy is more common

Answer

Cesarean section is more common

Answer

Eclampsia is more common

Answer

Maternal mortality rate is higher

Question 7

Which one of the following congenital malformations of the fetus can be diagnosed in the first trimester by ultrasound?

Accepted Answer

Anencephaly

Answer

Inencephaly

Answer

Microcephaly

Answer

Holoprosencephaly

Question 8

For fetal lung maturation, which of the following corticosteroids cannot be used?

Accepted Answer

Methylprednisolone

Answer

Betamethasone

Answer

Dexamethasone

Answer

Hydrocortisone

Question 9

What is the classical presentation of placenta previa?

Accepted Answer

Posterior

Answer

Answer

Central

Answer

Lateral

Question 10

What is the most important factor in the management of preeclampsia?

Accepted Answer

Severity of hypertension

Answer

Proteinuria

Answer

Convulsions

Answer

Pedal edema

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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